PREVIOUS EMPLOYMENT(Please List Last 2 Employers, Starting with the Most Recent)

Employment Application

PERSONAL INFORMATION

Full Name: / Date:
Last / First / M.I.
Address:
Street Address / Apartment/Unit #
City / State / ZIP Code
Phone: / ( ) / E-mail Address:
Primary Contact Method / Social Security No.:
JOB PREFERENCES
Position Applying for:
Date Available: / ___/___/____ / Desired Job Type: / Desired Salary: / $
Are you Employed now? / Yes No / Current Job Type:
Have you applied for Clinical Care Medical Centers before? / Yes No / If yes, when?
Have you ever worked for Clinical Care Medical Centers before? / Yes No / If yes, when?
Reason for leaving:

EDUCATION

High School: / Address:
From: / To: / Did you graduate? / Yes No / Degree:
College: / Address:
From: / To: / Did you graduate? / Yes No / Degree:
Other: / Address:
From: / To: / Did you graduate? / Yes No / Degree:

REFERENCES

Please list three (3) professional references.
Full Name: / Relationship:
Company: / Phone: / ( )
Full Name: / Relationship:
Company: / Phone: / ( )
Full Name: / Relationship:
Company: / Phone: / ( )

PREVIOUS EMPLOYMENT(please list last 2 employers, starting with the most recent)

Company: / Phone: / ( )
Address: / Supervisor:
Job Title: / Starting Salary: / $ / Ending Salary: / $
Responsibilities:
From: / To: / Reason for Leaving:
May we contact your previous supervisor for a reference? / Yes No
Company: / Phone: / ( )
Address: / Supervisor:
Job Title: / Starting Salary: / $ / Ending Salary: / $
Responsibilities:
From: / To: / Reason for Leaving:
May we contact your previous supervisor for a reference? / Yes No
Are you authorized to work in the United States:
I am authorized to work in this country for any employer
I require sponsorship to work in this country
My status to work in this country is unknown / Are you related to or know anyone who is employed with Clinical Care Medical Centers? Yes No
If yes, who? ______
Languages you speak, read and write: / Fluent Conversational Basic
Have you been convicted of a felony within the last 5 years? Yes No
If YES, explain (will not necessarily exclude you from consideration):
How did you hear about us? / If Employee Referral, who?

DISCLAIMER AND SIGNATURE

I certify that my answers are true and complete to the best of my knowledge and understand that, if employed; falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise and release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any unspecified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.
Signature: / Date: / ___/___/____